Physical Examination of the Heart (1)

心脏的物理检查（1)

Introduction.

导言

Careful physical examination of the heart provides important information about the cardiovascular system. Together with a thorough history, the physical examination provides the initial database and suggests further diagnostic tests and therapeutic maneuvers. In many conditions, careful physical examination can yield information as important as that obtained by more complex and costly procedures.

仔细的心脏物理检查可以提供心脏的重要信息。它和病史记录一起构成最初的基础数据，并为以后的诊断检查和治疗方法提供依据。对很多疾病而言，仔细的物理检查所提供的信息和通过其他复杂昂贵的手段所获得的信息一样重要。

It is also important to recognize the complex interplay between cardiac disease and other systemic illnesses or conditions. A common mistake made by the noncardiologist is ignoring the cardiac manifestations of a systemic disease process. Conversely, the cardiologist may fail to recognize the effects of cardiac disease on other organ systems. For these reasons every patient suspected of having cardiac abnormalities must be given a thorough physical examination.

认识心脏疾病与其他系统性疾病或病症之间复杂的相互作用关系也很重要。非心脏病医师常犯的错误是勿略了某一系统性疾病发展过程中心脏的症状，而心脏病医师也可能并未认识到心脏病对其他器管所造成的影响。有鉴于此，每一个怀疑有心脏异常的病人都必须作彻底的物理检查。

Observations, palpation, and percussion

望诊、触诊和叩诊

1. Jugular venous pulse (JVP). Two types of information are obtained from the JVP: the quality of the wave form and the central venous pressure (CVP).

1、颈静脉搏动（JVP)-- 颈静脉搏动可提供两类信息：波形特性和中心静脉压。

(1) Technique of examination. The JVP is best observed in the right internal jugular vein. With normal CVP, the JVP is assessed with the patient's trunk raised less than 30 degrees. With elevated CVP the patient's trunk must be raised higher, sometimes to as much as 90 degrees. The JVP is accentuated by turning the patient's head away from the examiner and shining a flashlight obliquely across the skin overlying the vein.

（1)检查方法 最佳观察位置是右侧颈内静脉。评估颈静脉搏动时，中心静脉压正常的病人的躯干伸直角度应小于30O；中心静脉压升高者的躯干直立角度应加大，有时可达90O。检查时，让患者侧过头去，并用手电筒斜照静脉上方皮肤，就可清楚看到颈静脉。

(2) Wave form of the JVP. Two waves per heartbeat are generally visible in the JVP: the A wave and the V wave. The A wave appears as a brief "flicker" and represents increased venous pressure resulting from atrial contraction. The V wave is a longer surge that follows the A wave and represents increased venous pressure transmitted during ventricular contraction. The drop in pressure following the A wave is called the X descent, and the fall in pressure after the V wave is denoted as the Y descent. The JVP waves should be timed with simultaneous palpation of the carotid artery. The A wave immediately precedes the carotid pulse; the V wave follows the pulse. The diagnosis of a variety of pathologic states is assisted by observation of abnormalities in the JVP wave forms　(Table 1-1).

（2)颈静脉波形 颈静脉搏动时，每次心跳通常都会出现两种波形：A波和V波。A波为短促的“扑动”，代表心房收缩产生的静脉压增加。V波为A波后的较长波涌，代表心室收缩期间传导的静脉压增加。A波后的脉压下降称为X下降，V波后的下降则称为Y下降。计算颈静脉搏动时应同步触诊颈动脉。A波先于颈动脉搏动；V波居后。颈静脉波形观察异常可支持各种病理状态的诊断（见表1-1)。

(3) Determination of CVP. CVP can be estimated by observing the vertical distance from the top of the V wave to the right atrium. In the individual with normal CVP, the V wave rises 1-2 cm above the sternal angle. When the V wave rises to more than halfway to the angle of the jaw in a patient who is not recumbent, elevated CVP is present. In some pathologic conditions (e.g., cardiac tamponade, constrictive pericarditis), CVP may be so high that A and V waves are above the angle of the jaw. In this setting, exaggerated X and Y descents may suggest the diagnosis. As a rule of thumb, for a patient sitting upright, a JVP visible at the sternal angle represents a CVP of approximately 10 mm Hg.

（3)中心静脉压测定 观察V波顶部至右心房的垂直距离即可估得中心静脉压。中心静脉压正常者，V波上升，高出胸骨角1 ~ 2cm。非横卧病人V波升离至颌角一半以上位置时，就会出现中心静脉压升高。有些病理情况（如心脏填塞、缩窄性心包炎)的中心静脉压可以升得很高，以致A波和V波都可高出颌角。此时，突出的X和Y下降提示诊断成立。根据经验，对一个端座病人来说，胸骨角颈静脉搏动就代表一个约10mmHg的中心静脉压。

During inspiration the height of the JVP typically declines (although amplitude of the X and Y descents will increase). In certain pathologic conditions such as chronic constrictive pericarditis and occasionally tricuspid stenosis, congestive heart failure, right ventricular dysfunction, or infarction the JVP actually increases with inspiration. This important clinical finding is known as Kussmaul's sign.

吸气期间，颈静脉搏动高度下降很典型（尽管X和Y下降的振幅加大)，但有些病理情况，如慢性缩窄性心包炎以及偶尔的三尖瓣狭窄、充血性心力衰竭、右心室功能不全或心肌梗死，其颈静脉搏动实际上是随吸气增加的。这一重要临床发现被称为库斯毛尔氏征。

2. Arterial pressure pulse. The central arterial pressure pulse is characterized by a rapid rise to a rounded shoulder peak with a less rapid decline. Information about the adequacy of ventricular contraction and possible obstruction of the left ventricular outflow tract may be assessed by palpation of the carotid artery. By the time the pulse wave is transmitted to peripheral arteries, much of this initial information is lost; however, pulsus alternans is best evaluated in peripheral arteries.医.学全.在.线网站www.lindalemus.com

2、动脉压搏动 中心动脉压搏动的特点是，迅速升高形成一个圆形肩峰，随后下降，但速度放慢。颈动脉触诊即可评估有关心室收缩充分及左心室流出通路可能堵塞的信息。脉波传到外周动脉时，此类初始信息会丢失很多。不过，最好是在外周动脉处评估交替脉。

A variety of pathologic conditions alters the characteristics of the carotid pulse. These conditions, and the corresponding modifications of the carotid pulse, are listed in Table 1-2. In patients with unexplained hypertension, simultaneous palpation of radial and femoral arterial pulses helps to rule out coarctation of the aorta.

有很多病理情况会改变颈动脉特征（见表1-2)。在不明因高血压患者中，同时触诊桡动脉和股动脉脉搏有助于排除主动脉缩窄。

3. Precordial palpation. Information concerning the location and quality of the left ventricular impulse is available through precordiat palpation. In addition, intensity of murmurs may be gauged by palpating associated thrills. Palpation is best accomplished using the fingertips, with the patient either supine or in the left lateral decubitus position. Simultaneous auscultation can aid in the timing of events. A list of abnormalities detected by precordial palpation and their significance is found in Table 1-3.

3、心前区触诊 心前区触诊可提供左心室冲动的位置及特征信息。此外，还可通过触诊相关震颤推断杂音的强度。触诊时最好用指尖，病人处仰卧位或左侧卧位。同步听诊有助于计数。心前区触诊异常及其临床意义见表1-3。

Auscultation

听诊

1. Sl. The first heart sound (SI) occurs at the time of closure of the mitral and tricuspid valves. It is probably generated by the closure of the valves. Si is frequently split (with mitral closure preceding tricuspid), but this event is often hard to appreciate and of little clinical relevance. More important is variation in intensity of the first sound. S1 varies with the P-R interval of the ECG. The shorter the P-R interval, the louder the Si. The best example of S1 variation with P-R interval occurs in complete heart block, in which atrial and ventricular contractions are dissociated.

1、S1 第一心音（S1)发生于二、三尖瓣关闭时，这可能是由瓣膜关闭造成的。S1常常呈分裂状（二尖瓣先于三尖瓣关闭)，但这一点又往往难以正确评估，也没有多少临床实用性。第一心音的强度变化更为重要。S1随ECG P-R间期而变。P-R间期越短，S1越大。S1随P-R间期而变的最好例子是在完全心脏传导阻滞期，此时的房、室收缩是分离的。

S1 may be loud and "snapping" in quality in mitral stenosis, indicating both that the valve is pliable and that it remains wide open at the beginning of isovolumic contraction. Conversely, a diminished or absent S1 in mitral stenosis suggests a rigidly calcified valve that cannot "snap" shut.

二尖瓣狭窄时S1响亮、呈喀嚓声，既表明瓣膜柔软，也表明瓣膜在等容量收缩开始时仍张开着。相反，二尖瓣狭窄时S1减弱或消失，表明瓣叶严重钙化，无法关闭。

Other situations in which S1 may be diminished include mitral regurgitation, slow heart rates (long P-R interval), poor sound conduction through the chest wall, and a slow rise of left ventricular pressure. A summary of clinical information derived from variations in S1 is found in Table 1-4.

S1可能减弱的其他情形包括二尖瓣反流、心率缓慢（P-R间期长)、胸腔壁声音传导差、左室压上升慢。S1变化情况见表1-4。医学.全.在线.网.站.提供

2. S2. In contrast to S1, in which splitting is less important than changes in intensity, S2 reveals variations in both splitting and intensity that provide important clinical information.

2、S2 在S1中，强度变化要比分裂重要。与此相反，S2 既反映分裂的变化，也反映强度的变化，从而提供重要的临床信息。

The second heart sound (S2) occurs at the time of closure of the aortic and pulmonic valves. In normal circumstances, aortic closure precedes pulmonic closure (A2 followed by P2). Under normal circumstances, the split in S2 is maximal at the end of Inspiration and minimal at the end of expiration. This phenomenon reflects an underlying movement of P2 with respect to a relatively constant A2. During inspiration, right ventricular filling increases and P2 is delayed, causing the widely split S2. During expiration, less right ventricular filling occurs and P2 "closes" toward A2, causing a diminished split in S2. This "normal splitting" of S2 is invariably present in individuals under 30 years of age, provided heart rates are not markedly accelerated. It is best appreciated over the "pulmonic area" and can be heard with either the bell or the diaphragm.

S2发生于主动脉瓣和肺动脉瓣关闭时。正常情况下，主动脉瓣关闭早于肺动脉瓣（A2先于P2)，S2分裂在吸气末最大，呼气末最小。这种现象反映了与A2相对衡定对应的P2潜在运动性。吸气期间，右室充盈增加，P2延迟，导致泛分裂S2。呼气期间，右室充盈减少，P2对A2“关闭”，导致S2分裂降低。在心律没有明显加速的情况下，30岁以下的个体中可始终见到这种S2“正常分裂”，在肺动脉区上方鉴别得最清楚，钟式听诊器或膈膜式听诊器都能听到。

(1) Fixed splitting of S2. The most common abnormality Of S2 is failure of splitting to close at the end of expiration. This "fixed splitting" occurs for either of two reasons: 1>2 is delayed or A2 is early. A split of S2 on expiration may also represent a normal variant. In the latter setting, however, some difference in the degree of split should occur between inspiration and expiration.

（1) S2的固定分裂 S2最常见的异常是分裂未能在呼气末关闭。这种“固定分裂”的发生不是由于P2延迟，就是由于A2较早。呼气时S2的分裂也可以是一种正常变数。不过，在后者情况下，应在吸气和呼气之间出现某种分裂程度上的差异。

Fixed splitting of S2 due to delayed P2 is found in four clinical settings: acute right-heart pressure overload (e.g., pulmonary embolism), right bundle branch block, atrial septal defect (ASD), and pulmonic stenosis.

由延迟P2引起的S2固定分裂见于下例四种临床环境：急性右心压力过载（如肺栓塞)、右束支传导阻滞、房间隔缺损、肺动脉瓣狭窄。

(2) Paradoxical splitting of S2. Paradoxical splitting of S2 is said to be present when S2 splits on expiration and closes on inspiration. Although fixed splitting denotes delay in normal closure of the pulmonic valve, paradoxical splitting denotes delayed closure of the aortic valve. This important clinical sign never occurs in the absence of cardiac disease. The most common states in which paradoxical splitting is encountered are aortic stenosis and left bundle branch block. Paradoxical splitting takes place in about 25% of individuals with these conditions.

（2) S2逆分裂 第二心音逆分裂据称是在S2呼气分裂、吸气关闭时出现的。固定分裂表明肺动脉瓣正常关闭的延迟，逆分裂则表明主动脉瓣关闭已经延迟。在无心脏病患者中决不会出现这种重要的临床症状。在主动脉瓣狭窄和左束支传导阻滞中，逆分裂见得最多，此类病人有25％会发生逆分裂。

Paradoxical splitting may occur in patients with coronary artery disease or hypertension or both. In these individuals a closely split S2 may be observed to close to a single sound at midinspiration. A similar finding is often made in early stages of aortic stenosis or in incomplete leil bundle branch block.

冠状动脉病人或高血压病人或两者兼而有之的病人可能发生逆分裂。在这些病人中，观察到的S2分裂衔接得很紧密，以致只能在吸气中段听到一个声音。在主动脉瓣狭窄早期或完全左束支传导阻滞病人中经常会发现类似的检查结果。

Alterations in the intensity of S2 can also yield important clinical information. A2 is frequently decreased in aortic stenosis. The presence of a normal A2 when aortic stenosis is clinically suspected raises the question of outflow obstruction at a site other than the valve. P2 may be augmented in pulmonary hypertension and diminished in pulmonic stenosis. Finally, P2 may appear unusually loud in thin-chested individuals without cardiac disease. A summary of clinical information derived from alterations in S2 is found in Table 1-5.

S2强度变化也可为我们提供重要的临床信息。主动脉瓣狭窄病人的A2通常降底，临床怀疑有主动脉瓣狭窄的病人如出现正常A2，则提示某一部位而非该瓣膜有流出道梗阻问题。肺动脉高血压可加剧P2，肺动脉瓣狭窄时则P2减轻。无心脏疾病的薄胸个体，P2可能会显得异常之大。S2变化情况见表1-5。

3. S3. The third heart sound (S3, or ventricular gallop) is low-pitched and best heard at the apex with the stethoscope bell. The S3 is probably the result of rapid filling and stretching of an abnormal left ventricle. The cadence of the S3 has been likened to the y in Kentucky. An S3 may be heard in any condition resulting in rapid ventricular filling. It is frequently an early sign of left ventricular failure. Third heart sounds may also be present in atrial septal defect, mitral or aortic insufficiency, ventricular septal defect, and patent ductus arteriosus. An S3 can also be a normal variant, particularly in young adults. A loud, early diastolic sound is often heard in constrictive pericarditis. This "pericardial knock" may be mistaken for an S3.

3、S3 第三心音，又叫室性奔马律，低音调，用钟式听诊器在心尖处听得最清楚。S3很可能是异常左室快速充盈和扩张的结果。导致心室快速充盈的任何病症都可以听到S3。它常常是左室衰竭的一个早期症状。房间隔缺损、二尖瓣或主动脉瓣关闭不全、室间隔缺损及动脉导管示闭等患者也可出现第三心音。限制性心包炎病人经常可听到响亮的早期舒张音。这种“心包叩击音”可以被误诊为S3。

4. S4. The fourth heart sound (S4, atrial gallop, presystolic gallop) is also the result of altered ventricular compliance. Its cadence has been likened to the soft a of appendix. It is a low-pitched sound, best heard with the stethoscope bell. It is loudest at the apex and may be accentuated by placing the patient in the left lateral decubitus position. The presence of an S4 implies effective atrial contraction; it is never heard in atrial fibrillation. An S4 may be heard in any condition causing reduced ventricular compliance: aortic stenosis, systemic or pulmonary hypertension, coronary artery disease, hypertrophic cardiomyopathy, acute mitral regurgitation, and myocardial infarction.

4、S4 第四心音，又叫房性奔马律，收缩期前奔马律，也是心室顺应性改变的结果。其音为低音调，用钟式听诊器听得最清楚。心尖部位最响亮，病人处左侧卧位时听得最清楚。S4的出现意味着心房收缩好，房性纤颤病人无S4。引起室顺应性降低的病症都可听到S4，如：主动脉瓣狭窄、系统性或肺动脉高血压、冠状动脉疾病及心肌梗死。